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75 Henley Beach Rd, Mile End, SA 5031

GYMVT Trial Form 

Rules & Regulations:

  1. Be there 5 mins SHARP prior to session commencing. This way there will be no problems with class formats set by instructor and you won’t be missing out on team warm ups (very important)! Punishments to group will be given to all arrivals over 1 minute late.
  2. Photo’s/videos could be taken during class and may/may not be uploaded to ‘GYMVT’ social media pages. You are entering into this agreement in connection with photographs and/or video footage taken during challenge, and have been informed and understand that ‘GYMVT’ may use your name, likeness, image, voice, signature, and/or appearance, without limitation, media publicity; website features; magazine articles; video press kits; supplemental materials .
  3. If you are over 10 mins late to a session you will not be permitted to join in for the same reasons as rule 1 plus more importantly you are at higher risk of injury without the group warm up.
  4. If you are holding any sort of injury, the trainer will do their best to accommodate you, do your best to give notice on injuries that you are aware of.
  5. Please drink before, during and post class to stay hydrated, you should be drinking 1 litre per 25kg of body weight, plus an additional 1 litre per hour of exercise. And EAT at least before or after class to stay fuelled for your day.
  6. If you have dizzy spells, feel sick or in general not feeling 100%, tell the trainer immediately without hesitation

Terms & Conditions:

Suspension: Member requesting suspension must email a clear photo of their form to info@gymvt.com 14 DAY’S prior to requested date. This form can be found on our website. Please note there is a minimum 14 day suspension and maximum 4 week suspension period.

Cancellation: Member requesting cancellation must email a clear photo of their form to info@gymvt.com 28 DAY’S prior to requested date. This form can be found on our website.

There is a minimum 26-week active membership period after joining & there are no suspension/cancellation fees after this period. You may suspend or cancel your membership whenever you like given suspension/cancellation form is filled out correctly & above T&C’s are followed. Joining fees will apply again if you cancel your membership & wish to re-join in the future. There is a no refund policy on un used gym membership, advanced payments/deposits, or if you were late to hand in a suspension/cancellation request form.

Promotions: Membership payment will continue as per normal after any purchased promotions come to an end, unless you give notice for no membership continuation 1 week prior to promotion finishing date.

Personal Training: You must give 24 HOURS’ notice (to your trainer) to reschedule a PT session & 14 DAY’S notice (to your trainer) to cancel a PT session. Each session is a 30-minute appointment which may be followed by another client. You are asked to be on time for your session as it will conclude at the scheduled time even if you are late. If you are more than 15 minutes late, this is considered a cancellation.

Agreement for participating in Personal Strength, Fitness and Conditioning Training:

Please read this section completely. This is a legal document and affects your rights.

The “Trainer” refers to the Australian registered business, GYMVT Pty Ltd. The “Activity” refers to participation in personal strength, fitness and conditioning training and general advices at the gym, offsite from the gym, at home and/or from any training programs.

I, whose signature appears below, acknowledge that is a condition of participating in this activity that I do so at my own risk. I accept all risks and hereby indemnify and release the trainer, their agents, affiliates, employees, members, sponsors, promoters and any person or body directly or indirectly associated with the trainer, against all liability (including liability for their negligence and negligence of others) claims, demands, and proceedings arising out or connected with my participation in this activity. This release and indemnity continues forever and binds my heirs, successors, executors, personal representatives and assigns. I acknowledge that participating in this activity may involve risk or serious injury or even death from various causes, including over exertion, dehydration, equipment failure and accidents with equipment and surroundings. I recognise the difficulties associated with the activity and attest that I am physically fit to participate safely in the activity and that a qualified medical practitioner has not advised me otherwise. I understand the demanding physical nature of this activity. I am not aware of any medical condition, injury or impairment that will be detrimental to my health if I participate in this activity. In the event that I become aware of any medical condition, injury or impairment that will be detrimental to my health if I participate in this activity my trainer will be immediately informed. By continuing to participate in the activity, I accept the risks despite these conditions and am still, and always will be under the terms of this agreement. If in the unlikely case an ambulance is called for me, I accept that am liable to cover any medical bills that may occur to me afterwards. I certify that I am 18 years or older and have read this document and fully understand it
OR
As a parent/guardian of the participant/s I (a) agree to the above for myself and on behalf of the participant and (b) I indemnify and will keep indemnified any person or body directly or indirectly associated with the conduct of the activity on the terms referred to.

*I AM ALSO 100% LIABLE FOR ANY INJURY OR HARM CAUSED TO MY BABY/CHILD BEFORE, DURING, OR AFTER FITNESS CLASSES OR PT AT GYMVT*

Today's Date: May 28, 2020       

I Agree

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information

Health Screen 

Regular physical activity is fun and healthy, and increasingly more people are starting to become more active every day. Being more active is very safe for most people. However, some people should check with their doctor before they start becoming much more physically active. If you are planning to become much more physically active than you are now, your complete and honest responses to the following questions are essential

Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?*
No
Yes
Do you feel pain in your chest when you do physical activity?*
No
Yes
In the past month, have you had chest pain when you were not doing physical activity?*
No
Yes
Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?*
No
Yes
Do you have kidney disease, stroke, epilepsy or arthritis?*
No
Yes
Have you had a stroke?*
No
Yes
Has your doctor said you have heart or vascular disease?*
No
Yes
Do you have pulmonary disease or cystic fibrosis?*
No
Yes
Are you pregnant or trying to conceive?*
No
Yes
Do you experience unreasonable breathlessness?*
No
Yes
Do you take prescription medications?*
No
Yes
Do you take heart medication?*
No
Yes
Do you have blood pressure over 140/90?*
No
Yes
Do you take blood pressure medication?*
No
Yes
Do you have a family history of heart attack?*
No
Yes
Do you have cholesterol more than 240mg/dl?*
No
Yes

If you answered YES to one or more questions: Talk with your doctor by phone or in person BEFORE you start becoming much more physically active, Tell your doctor about the PAR-Q and which questions you answered YES. You may be able to do any activity you want -as long as you start slowly and build up gradually or, you may need to restrict your activities to those which are safe for you. Talk with your doctor and follow the advice you are given. 

If you answered NO to all questions: You can be reasonably sure that you can exercise safely and have low risk of having any medical complications from exercise. It is still important to start slowly and increase gradually. A fitness assessment which we will conduct is important to help us assess your current fitness level.

First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information

Health Screen 

Regular physical activity is fun and healthy, and increasingly more people are starting to become more active every day. Being more active is very safe for most people. However, some people should check with their doctor before they start becoming much more physically active. If you are planning to become much more physically active than you are now, your complete and honest responses to the following questions are essential

Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?*
No
Yes
Do you feel pain in your chest when you do physical activity?*
No
Yes
In the past month, have you had chest pain when you were not doing physical activity?*
No
Yes
Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?*
No
Yes
Do you have kidney disease, stroke, epilepsy or arthritis?*
No
Yes
Have you had a stroke?*
No
Yes
Has your doctor said you have heart or vascular disease?*
No
Yes
Do you have pulmonary disease or cystic fibrosis?*
No
Yes
Are you pregnant or trying to conceive?*
No
Yes
Do you experience unreasonable breathlessness?*
No
Yes
Do you take prescription medications?*
No
Yes
Do you take heart medication?*
No
Yes
Do you have blood pressure over 140/90?*
No
Yes
Do you take blood pressure medication?*
No
Yes
Do you have a family history of heart attack?*
No
Yes
Do you have cholesterol more than 240mg/dl?*
No
Yes

If you answered YES to one or more questions: Talk with your doctor by phone or in person BEFORE you start becoming much more physically active, Tell your doctor about the PAR-Q and which questions you answered YES. You may be able to do any activity you want -as long as you start slowly and build up gradually or, you may need to restrict your activities to those which are safe for you. Talk with your doctor and follow the advice you are given. 

If you answered NO to all questions: You can be reasonably sure that you can exercise safely and have low risk of having any medical complications from exercise. It is still important to start slowly and increase gradually. A fitness assessment which we will conduct is important to help us assess your current fitness level.

Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information

Health Screen 

Regular physical activity is fun and healthy, and increasingly more people are starting to become more active every day. Being more active is very safe for most people. However, some people should check with their doctor before they start becoming much more physically active. If you are planning to become much more physically active than you are now, your complete and honest responses to the following questions are essential

Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?*
No
Yes
Do you feel pain in your chest when you do physical activity?*
No
Yes
In the past month, have you had chest pain when you were not doing physical activity?*
No
Yes
Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?*
No
Yes
Do you have kidney disease, stroke, epilepsy or arthritis?*
No
Yes
Have you had a stroke?*
No
Yes
Has your doctor said you have heart or vascular disease?*
No
Yes
Do you have pulmonary disease or cystic fibrosis?*
No
Yes
Are you pregnant or trying to conceive?*
No
Yes
Do you experience unreasonable breathlessness?*
No
Yes
Do you take prescription medications?*
No
Yes
Do you take heart medication?*
No
Yes
Do you have blood pressure over 140/90?*
No
Yes
Do you take blood pressure medication?*
No
Yes
Do you have a family history of heart attack?*
No
Yes
Do you have cholesterol more than 240mg/dl?*
No
Yes

If you answered YES to one or more questions: Talk with your doctor by phone or in person BEFORE you start becoming much more physically active, Tell your doctor about the PAR-Q and which questions you answered YES. You may be able to do any activity you want -as long as you start slowly and build up gradually or, you may need to restrict your activities to those which are safe for you. Talk with your doctor and follow the advice you are given. 

If you answered NO to all questions: You can be reasonably sure that you can exercise safely and have low risk of having any medical complications from exercise. It is still important to start slowly and increase gradually. A fitness assessment which we will conduct is important to help us assess your current fitness level.

Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information

Health Screen 

Regular physical activity is fun and healthy, and increasingly more people are starting to become more active every day. Being more active is very safe for most people. However, some people should check with their doctor before they start becoming much more physically active. If you are planning to become much more physically active than you are now, your complete and honest responses to the following questions are essential

Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?*
No
Yes
Do you feel pain in your chest when you do physical activity?*
No
Yes
In the past month, have you had chest pain when you were not doing physical activity?*
No
Yes
Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?*
No
Yes
Do you have kidney disease, stroke, epilepsy or arthritis?*
No
Yes
Have you had a stroke?*
No
Yes
Has your doctor said you have heart or vascular disease?*
No
Yes
Do you have pulmonary disease or cystic fibrosis?*
No
Yes
Are you pregnant or trying to conceive?*
No
Yes
Do you experience unreasonable breathlessness?*
No
Yes
Do you take prescription medications?*
No
Yes
Do you take heart medication?*
No
Yes
Do you have blood pressure over 140/90?*
No
Yes
Do you take blood pressure medication?*
No
Yes
Do you have a family history of heart attack?*
No
Yes
Do you have cholesterol more than 240mg/dl?*
No
Yes

If you answered YES to one or more questions: Talk with your doctor by phone or in person BEFORE you start becoming much more physically active, Tell your doctor about the PAR-Q and which questions you answered YES. You may be able to do any activity you want -as long as you start slowly and build up gradually or, you may need to restrict your activities to those which are safe for you. Talk with your doctor and follow the advice you are given. 

If you answered NO to all questions: You can be reasonably sure that you can exercise safely and have low risk of having any medical complications from exercise. It is still important to start slowly and increase gradually. A fitness assessment which we will conduct is important to help us assess your current fitness level.

Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information

Health Screen 

Regular physical activity is fun and healthy, and increasingly more people are starting to become more active every day. Being more active is very safe for most people. However, some people should check with their doctor before they start becoming much more physically active. If you are planning to become much more physically active than you are now, your complete and honest responses to the following questions are essential

Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?*
No
Yes
Do you feel pain in your chest when you do physical activity?*
No
Yes
In the past month, have you had chest pain when you were not doing physical activity?*
No
Yes
Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?*
No
Yes
Do you have kidney disease, stroke, epilepsy or arthritis?*
No
Yes
Have you had a stroke?*
No
Yes
Has your doctor said you have heart or vascular disease?*
No
Yes
Do you have pulmonary disease or cystic fibrosis?*
No
Yes
Are you pregnant or trying to conceive?*
No
Yes
Do you experience unreasonable breathlessness?*
No
Yes
Do you take prescription medications?*
No
Yes
Do you take heart medication?*
No
Yes
Do you have blood pressure over 140/90?*
No
Yes
Do you take blood pressure medication?*
No
Yes
Do you have a family history of heart attack?*
No
Yes
Do you have cholesterol more than 240mg/dl?*
No
Yes

If you answered YES to one or more questions: Talk with your doctor by phone or in person BEFORE you start becoming much more physically active, Tell your doctor about the PAR-Q and which questions you answered YES. You may be able to do any activity you want -as long as you start slowly and build up gradually or, you may need to restrict your activities to those which are safe for you. Talk with your doctor and follow the advice you are given. 

If you answered NO to all questions: You can be reasonably sure that you can exercise safely and have low risk of having any medical complications from exercise. It is still important to start slowly and increase gradually. A fitness assessment which we will conduct is important to help us assess your current fitness level.

Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information

Health Screen 

Regular physical activity is fun and healthy, and increasingly more people are starting to become more active every day. Being more active is very safe for most people. However, some people should check with their doctor before they start becoming much more physically active. If you are planning to become much more physically active than you are now, your complete and honest responses to the following questions are essential

Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?*
No
Yes
Do you feel pain in your chest when you do physical activity?*
No
Yes
In the past month, have you had chest pain when you were not doing physical activity?*
No
Yes
Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?*
No
Yes
Do you have kidney disease, stroke, epilepsy or arthritis?*
No
Yes
Have you had a stroke?*
No
Yes
Has your doctor said you have heart or vascular disease?*
No
Yes
Do you have pulmonary disease or cystic fibrosis?*
No
Yes
Are you pregnant or trying to conceive?*
No
Yes
Do you experience unreasonable breathlessness?*
No
Yes
Do you take prescription medications?*
No
Yes
Do you take heart medication?*
No
Yes
Do you have blood pressure over 140/90?*
No
Yes
Do you take blood pressure medication?*
No
Yes
Do you have a family history of heart attack?*
No
Yes
Do you have cholesterol more than 240mg/dl?*
No
Yes

If you answered YES to one or more questions: Talk with your doctor by phone or in person BEFORE you start becoming much more physically active, Tell your doctor about the PAR-Q and which questions you answered YES. You may be able to do any activity you want -as long as you start slowly and build up gradually or, you may need to restrict your activities to those which are safe for you. Talk with your doctor and follow the advice you are given. 

If you answered NO to all questions: You can be reasonably sure that you can exercise safely and have low risk of having any medical complications from exercise. It is still important to start slowly and increase gradually. A fitness assessment which we will conduct is important to help us assess your current fitness level.

Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information

Health Screen 

Regular physical activity is fun and healthy, and increasingly more people are starting to become more active every day. Being more active is very safe for most people. However, some people should check with their doctor before they start becoming much more physically active. If you are planning to become much more physically active than you are now, your complete and honest responses to the following questions are essential

Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?*
No
Yes
Do you feel pain in your chest when you do physical activity?*
No
Yes
In the past month, have you had chest pain when you were not doing physical activity?*
No
Yes
Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?*
No
Yes
Do you have kidney disease, stroke, epilepsy or arthritis?*
No
Yes
Have you had a stroke?*
No
Yes
Has your doctor said you have heart or vascular disease?*
No
Yes
Do you have pulmonary disease or cystic fibrosis?*
No
Yes
Are you pregnant or trying to conceive?*
No
Yes
Do you experience unreasonable breathlessness?*
No
Yes
Do you take prescription medications?*
No
Yes
Do you take heart medication?*
No
Yes
Do you have blood pressure over 140/90?*
No
Yes
Do you take blood pressure medication?*
No
Yes
Do you have a family history of heart attack?*
No
Yes
Do you have cholesterol more than 240mg/dl?*
No
Yes

If you answered YES to one or more questions: Talk with your doctor by phone or in person BEFORE you start becoming much more physically active, Tell your doctor about the PAR-Q and which questions you answered YES. You may be able to do any activity you want -as long as you start slowly and build up gradually or, you may need to restrict your activities to those which are safe for you. Talk with your doctor and follow the advice you are given. 

If you answered NO to all questions: You can be reasonably sure that you can exercise safely and have low risk of having any medical complications from exercise. It is still important to start slowly and increase gradually. A fitness assessment which we will conduct is important to help us assess your current fitness level.

Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information

Health Screen 

Regular physical activity is fun and healthy, and increasingly more people are starting to become more active every day. Being more active is very safe for most people. However, some people should check with their doctor before they start becoming much more physically active. If you are planning to become much more physically active than you are now, your complete and honest responses to the following questions are essential

Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?*
No
Yes
Do you feel pain in your chest when you do physical activity?*
No
Yes
In the past month, have you had chest pain when you were not doing physical activity?*
No
Yes
Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?*
No
Yes
Do you have kidney disease, stroke, epilepsy or arthritis?*
No
Yes
Have you had a stroke?*
No
Yes
Has your doctor said you have heart or vascular disease?*
No
Yes
Do you have pulmonary disease or cystic fibrosis?*
No
Yes
Are you pregnant or trying to conceive?*
No
Yes
Do you experience unreasonable breathlessness?*
No
Yes
Do you take prescription medications?*
No
Yes
Do you take heart medication?*
No
Yes
Do you have blood pressure over 140/90?*
No
Yes
Do you take blood pressure medication?*
No
Yes
Do you have a family history of heart attack?*
No
Yes
Do you have cholesterol more than 240mg/dl?*
No
Yes

If you answered YES to one or more questions: Talk with your doctor by phone or in person BEFORE you start becoming much more physically active, Tell your doctor about the PAR-Q and which questions you answered YES. You may be able to do any activity you want -as long as you start slowly and build up gradually or, you may need to restrict your activities to those which are safe for you. Talk with your doctor and follow the advice you are given. 

If you answered NO to all questions: You can be reasonably sure that you can exercise safely and have low risk of having any medical complications from exercise. It is still important to start slowly and increase gradually. A fitness assessment which we will conduct is important to help us assess your current fitness level.

Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information

Health Screen 

Regular physical activity is fun and healthy, and increasingly more people are starting to become more active every day. Being more active is very safe for most people. However, some people should check with their doctor before they start becoming much more physically active. If you are planning to become much more physically active than you are now, your complete and honest responses to the following questions are essential

Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?*
No
Yes
Do you feel pain in your chest when you do physical activity?*
No
Yes
In the past month, have you had chest pain when you were not doing physical activity?*
No
Yes
Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?*
No
Yes
Do you have kidney disease, stroke, epilepsy or arthritis?*
No
Yes
Have you had a stroke?*
No
Yes
Has your doctor said you have heart or vascular disease?*
No
Yes
Do you have pulmonary disease or cystic fibrosis?*
No
Yes
Are you pregnant or trying to conceive?*
No
Yes
Do you experience unreasonable breathlessness?*
No
Yes
Do you take prescription medications?*
No
Yes
Do you take heart medication?*
No
Yes
Do you have blood pressure over 140/90?*
No
Yes
Do you take blood pressure medication?*
No
Yes
Do you have a family history of heart attack?*
No
Yes
Do you have cholesterol more than 240mg/dl?*
No
Yes

If you answered YES to one or more questions: Talk with your doctor by phone or in person BEFORE you start becoming much more physically active, Tell your doctor about the PAR-Q and which questions you answered YES. You may be able to do any activity you want -as long as you start slowly and build up gradually or, you may need to restrict your activities to those which are safe for you. Talk with your doctor and follow the advice you are given. 

If you answered NO to all questions: You can be reasonably sure that you can exercise safely and have low risk of having any medical complications from exercise. It is still important to start slowly and increase gradually. A fitness assessment which we will conduct is important to help us assess your current fitness level.

Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information

Health Screen 

Regular physical activity is fun and healthy, and increasingly more people are starting to become more active every day. Being more active is very safe for most people. However, some people should check with their doctor before they start becoming much more physically active. If you are planning to become much more physically active than you are now, your complete and honest responses to the following questions are essential

Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?*
No
Yes
Do you feel pain in your chest when you do physical activity?*
No
Yes
In the past month, have you had chest pain when you were not doing physical activity?*
No
Yes
Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?*
No
Yes
Do you have kidney disease, stroke, epilepsy or arthritis?*
No
Yes
Have you had a stroke?*
No
Yes
Has your doctor said you have heart or vascular disease?*
No
Yes
Do you have pulmonary disease or cystic fibrosis?*
No
Yes
Are you pregnant or trying to conceive?*
No
Yes
Do you experience unreasonable breathlessness?*
No
Yes
Do you take prescription medications?*
No
Yes
Do you take heart medication?*
No
Yes
Do you have blood pressure over 140/90?*
No
Yes
Do you take blood pressure medication?*
No
Yes
Do you have a family history of heart attack?*
No
Yes
Do you have cholesterol more than 240mg/dl?*
No
Yes

If you answered YES to one or more questions: Talk with your doctor by phone or in person BEFORE you start becoming much more physically active, Tell your doctor about the PAR-Q and which questions you answered YES. You may be able to do any activity you want -as long as you start slowly and build up gradually or, you may need to restrict your activities to those which are safe for you. Talk with your doctor and follow the advice you are given. 

If you answered NO to all questions: You can be reasonably sure that you can exercise safely and have low risk of having any medical complications from exercise. It is still important to start slowly and increase gradually. A fitness assessment which we will conduct is important to help us assess your current fitness level.

Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email
Check to receive information, news, and discounts by e-mail.
A signed copy of this waiver will be sent to the email address you provide.
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Referral
How did you hear about us??*
Who's a friend you'd like to come train with you?

Name: *

Number: *
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Health Screen 

Regular physical activity is fun and healthy, and increasingly more people are starting to become more active every day. Being more active is very safe for most people. However, some people should check with their doctor before they start becoming much more physically active. If you are planning to become much more physically active than you are now, your complete and honest responses to the following questions are essential

Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?*
No
Yes
Do you feel pain in your chest when you do physical activity?*
No
Yes
In the past month, have you had chest pain when you were not doing physical activity?*
No
Yes
Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?*
No
Yes
Do you have kidney disease, stroke, epilepsy or arthritis?*
No
Yes
Have you had a stroke?*
No
Yes
Has your doctor said you have heart or vascular disease?*
No
Yes
Do you have pulmonary disease or cystic fibrosis?*
No
Yes
Are you pregnant or trying to conceive?*
No
Yes
Do you experience unreasonable breathlessness?*
No
Yes
Do you take prescription medications?*
No
Yes
Do you take heart medication?*
No
Yes
Do you have blood pressure over 140/90?*
No
Yes
Do you take blood pressure medication?*
No
Yes
Do you have a family history of heart attack?*
No
Yes
Do you have cholesterol more than 240mg/dl?*
No
Yes

If you answered YES to one or more questions: Talk with your doctor by phone or in person BEFORE you start becoming much more physically active, Tell your doctor about the PAR-Q and which questions you answered YES. You may be able to do any activity you want -as long as you start slowly and build up gradually or, you may need to restrict your activities to those which are safe for you. Talk with your doctor and follow the advice you are given. 

If you answered NO to all questions: You can be reasonably sure that you can exercise safely and have low risk of having any medical complications from exercise. It is still important to start slowly and increase gradually. A fitness assessment which we will conduct is important to help us assess your current fitness level.

Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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